<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015600341
Report Date: 05/03/2024
Date Signed: 05/03/2024 10:44:10 AM


Document Has Been Signed on 05/03/2024 10:44 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612



FACILITY NAME:CARLTON PLAZA OF SAN LEANDROFACILITY NUMBER:
015600341
ADMINISTRATOR:NANCY RANDHAWAFACILITY TYPE:
740
ADDRESS:1000 EAST 14TH ST.TELEPHONE:
(510) 636-0660
CITY:SAN LEANDROSTATE: CAZIP CODE:
94577
CAPACITY:199CENSUS: 143DATE:
05/03/2024
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
09:05 AM
MET WITH:Evelyn Jensen, Executive Director TIME COMPLETED:
11:00 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 05/03/24 at 9:05AM, Licensing Program Analyst (LPA) J. Clancy-Czuleger conducted an unannounced Health and Safety check due to the department receiving a priority 1 complaint.

During the health and safety check, LPA observed a total 143 residents at the facility. LPA toured facility with Executive Director, including but not limited to bedrooms, kitchen, dining rooms, activities rooms, bathroom, outdoor garden and common areas. LPA observed residents comfortable in their surroundings, eating their breakfast meals and relaxing in common areas with family and friends. Residents in care appear to be safe and there are no imminent health/safety concerns on today's date.

No deficiencies cited during the health and safety check.

Exit interview conducted and a copy of this report provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Jill Clancy-CzulegerTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 05/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/03/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1